Role of computed tomography in the assessment of caustic ingestion severity: A comprehensive review

Table 1 Summary of studies reporting on the role of contrast-enhanced computed tomography in the emergency diagnosis of caustic ingestion

Ref.	Country	Enrollment period	Stud design	Patients, n	Inclusion criteria	Exclusion criteria	Study aim	Results
Lurie et al[22], 2013	Israel	2000-2012	R	23	Adult patients (> 18 years) with caustic ingestion who underwent both CT and EGD within 48 hours of hospital admission		To evaluate the role of CT in assessing the severity of caustic injury	Endoscopy grading higher than CT grading in 14 patients (66%). Sensitivities of endoscopy grades 2b/3 to predict mortality and emergency laparotomy: 1 and 0.8, respectively. Specificities of endoscopy grades 2b/3 to predict mortality and emergency laparotomy: 0.38 and 0.37, respectively. Sensitivities of CT grade 3 to predict mortality and emergency laparotomy: 0.4 and 0.28, respectively. Specificities of CT grade 3 to predict mortality and emergency laparotomy: 0.94 and 0.93, respectively
Chirica et al[23], 2015	France	2000-2007 (1st stage). 2007-2012 (2nd stage)	R (1st stage). P (2nd stage)	197	Adult patients (> 16 years) with Zargar grade 3b esophageal necrosis	Patients with signs of peritonitis, hemodynamic instability, or Zargar grades < 3b	To evaluate the role of CT in selecting patients with Zargar grade 3b esophageal necrosis for emergent esophagectomy	Higher overall survival in the CT group compared to the routine-esophagectomy group in the crude (HR: 0.43; 95%CI: 0.21–0.85; P = 0.015) and the matched analysis (HR: 0.36; 95%CI: 0.16–0.79; P = 0.011). Native functioning esophagus rate higher in the CT group (38 % vs 1 %, P < 0.0001)
Chirica et al[24], 2016	France	2013-2014	P	120	Adult patients (> 16 years) with caustic injury	Patients with signs of peritonitis or hemodynamic instability	To evaluate the role of CT for the emergency diagnostic work-up of caustic injury	CT-alone algorithm would have spared 19 unnecessary esophagectomies and 16 explorative laparotomies compared with an endoscopy-alone algorithm. Endoscopy never rectified a wrong CT decision. CT never indicated transmural necrosis in low-grade endoscopic injuries
Bahrami-Motlagh et al[25], 2017	Iran	2015	P	34	Adult patients (> 15 years) with caustic injury	Patients with hemodynamic instability, third-degree burns of the hypopharynx, respiratory distress, history of a chronic disease or lesion in stomach/esophagus, or suspected GI perforation	To evaluate the screening performance characteristics of CT in caustic injury	Agreement rate between CT and endoscopy regarding the grade of esophageal and gastric injuries: Moderate (k = 0.38; P = 0.001) and fair (k = 0.17; P = 0.038), respectively. Sensitivity and specificity of CT in detecting esophageal damage: 96.29 and 57.14, respectively. Sensitivity and specificity of CT in detecting gastric damage: 89.65 and 40.00, respectively. AUROC of CT in the detection of esophageal and gastric damages: 0.76 (95%CI: 0.52-1.00) and 0.64 (95%CI: 0.35-0.94), respectively
Mensier et al[26], 2020	France	2014-2017	P	30	Patients with Zargar grade 3b gastric necrosis		To identify CT signs of irreversible gastric necrosis in Zargar 3 gastric necrosis	MPD consistently found in patients who underwent surgery for GI distress, and consistently absent in unoperated patients (except in one patient who refused surgery). Sensitivity and specificity of MPD for irreversible gastric necrosis: 80% and 95%, respectively. Positive and negative predictive values of MPD for irreversible gastric necrosis: 88% and 90%, respectively
Assalino et al[27], 2022	France	2013-2019	P	414	Adult patients (> 16 years) with caustic injury		To evaluate outcomes of caustic ingestion patients managed by a CT-based algorithm and the feasibility of abandoning emergency endoscopy	On crude analysis, similar overall survival in endoscopy-CT and CT-only algorithm groups; better functional outcomes in the CT-only group. On propensity match analysis, similar functional outcomes and overall survival in both groups. On multivariate analysis, intentional ingestion (P < 0.016), age (P < 0.0001), and the CT grade of esophageal injuries (P < 0.0001) were independent predictors of survival. The CT grade of esophageal injuries was the only independent predictor of success (P < 0.0001)
Tosca et al[28], 2022	Spain	1995-2021	P	532	Adult patients (> 15 years) with caustic injury	Doubtful or nonsignificant intake of a very low volume of a caustic substance	To compare a diagnostic algorithm based on predictive factors of an adverse clinical course (predictive algorithm) with a CT-based (radiological algorithm) and a combined approach based on the kind of ingestion, symptoms, and endoscopy (classical algorithm)	Significantly higher sensitivity for detecting any adverse outcome of predictive algorithm (87.1%; 95%CI: 77.3–93.0) than radiological (64.7%; 95%CI: 41.3–82.7) and classical (51.4%; 95%CI: 40.0–63.1) ones. Higher specificity for detecting any adverse outcome of predictive (96.1%; 95%CI: 93.9–97.5) and classical algorithm (98.7%; 95%CI: 97.2–99.4) than radiological one (70.0%; 95%CI). Significantly higher diagnostic OR of predictive (167.2; 95%CI: 71.9–388.7) and classical (80.5; 95%CI: 31.7–204.3) algorithms than radiological one (4.3; 95%CI: 0.8–22.9). Significantly higher proportion of patients requiring no examination for predictive algorithm (50.6%; 95%CI: 46.2%–55.1%) than classical (34.5%; 95%CI: 30.5%–38.6%) and radiological ones (0.0%; 95%CI: 0.0%–0.0%)
Chen et al[29], 2022	Taiwan	2014-2019	R	163	Adult patients (> 18 years) with caustic injury		To evaluate a diagnostic and management algorithm that combines EGD and CT for rapid triage	Significant correlation of EGD grade with the emergency surgical need in both univariate (OR = 8.556; 95%CI: 1.622–45.136; P = 0.011) and multivariate analysis (OR = 8.555; 95%CI: 1.559–46.942; P = 0.013). No significant correlation of CT grade with the emergency surgical need in both univariate (OR = 2.250; 95%CI: 0.497–10.178; P = 0.292) and multivariate analysis (OR = 0.350; 95%CI: 0.028–4.360; P = 0.415). AUROC of EGD, CT, and combined EGD-CT for emergency surgical need: 0.82 (P = 0.002), 0.58 (P = 0.420), and 0.78 (P = 0.007), respectively
Kaewlai et al[30], 2023	Thailand	2016-2021	R	17	Adult patients (> 18 years) with caustic injury who underwent CT within 72 hours of their admission	Endoscopy or surgery not performed	To identify and assess the CT findings differentiating the lack of transmural GI necrosis from its presence and the diagnostic performance of individual CT findings in diagnosing transmural GI necrosis	The highly differentiating CT findings between those with and without transmural GI necrosis were esophageal wall thickening (100% vs 42%, 0.001; 100% sensitive), gastric abnormal wall enhancement and fat stranding (100% vs 57%, 0.006; 100% sensitive), and gastric absent wall enhancement (46% vs 5%, 0.007; 100% specific). The intra- and interobserver agreements were 47%–100%, and 54%–100%, which increased to 53%–100%, and 60%–100%, respectively, when considering only radiologists’ reinterpretations
Scriba et al[31], 2024	South Africa	2017-2023	R	100	Adult patients with caustic injury	Patients managed for only the chronic sequelae of corrosive ingestion and those where acute management data was lacking	To investigate the applicability of parameters for predicting full-thickness necrosis and mortality	Good predictive performance for full-thickness necrosis of Zargar ≥ 3b, grade 3 CT, pH, base excess, and lactate, on multivariate analysis. Best predictive performance for full-thickness necrosis of endoscopy (AUROC = 0.850)

R: Retrospective; CT: Computed tomography; EGD: Esophagogastroduodenoscopy; P: Prospective; HR: Hazard ratio; CI: Confidence interval; GI: Gastrointestinal; AUROC: Area Under the Receiver Operating Characteristic Curve; MPD: Mucosal perfusion defect; OR: Odds ratio; GI: Gastrointestinal.